Evidence for

Psychodynamic Therapy

in Specific Mental Disorders

Prof. Dr. Falk Leichsenring

Clinic of Psychosomatics and Psychotherapy University of Giessen

Criteria of Evidence-based Medicine

n Evidence-based Medicine Working Group (Sacket, 1989; Cook et al., 1995; Guyatt et al., 1995)

n Canadian Task Force on the Periodic Health Examination (1979, 2004)

n Cochrane Collaboration (Clark & Oxman, 2003)

n American Psychological Association (APA, Chambless & Hollon, 1998)

n Roth & Fonagy (2005)

n Nathan & Gorman (2015)

Psychotherapy Research

Criteria for Efficacy

n Randomized Controlled Trials (RCTs): "Gold Standard"

n Random assignment to treament conditions

n Comparison with a control condition

n Use of treatment manuals

n Specific mental disorder (e.g. Social Phobia or PTSD)

n Critical discussion of RCTs

Strengths and Limitations of RCTs (Efficacy Studies)

n controlled experimental conditions

n internal validity usually high

n external validity may be limited (not sufficiently representative of clin. practice

n effectiveness studies; conditions of clinical practice

Review on the Efficacy of Psychodynamic Therapy

n Using the criteria of EBM/APA

n Randomized Controlled Trials (RCTs)

n Treatment Manuals

n Treatment of a specific mental disorder

Method

n Computerized Search (MEDLINE, PsycINFO)

n Key words: psychodynamic, psychoanalytic,

(psycho-) therapy, empirical study

n Textbooks, Journal Articles

n Period: 1960 – September 2017

Results

n Screen a large number of journal articles

n “Digging for Gold“

n RCTs fulfilling the inclusion criteria

Depressive Disorders (MDD)

n RCTs: STPP vs. Cognitive-Behavioral Therapy (CBT)

n STPP = CBT n Thompson et al. (1987; Gallagher-Thompson et al., 1990)

n Gallagher et al. (1994)

n Shapiro et al. (1994; 1995)

n Barkham et al. (1996)

n Cooper et al (2003)

n Driessen et al (2013): STPP: N=177 CBT: N=164 Remission: 24% vs. 21%

n Connolly et al (2016): STPP: N=118 CBT: N=119

Depressive Disorders

n Meta-Analyses

Leichsenring (2001): STPP=CBT

Cuipers et al (2009): STPP=CBT=IPT

Driessen et al (2015): STPP (individual) = other psychotherapies (individual)

Anxiety Disorders

n Milrod et al. (2007): Panic Disordern STPP > CBT (Applied Relaxation, Öst)

n Milrod et al. (2015): Panic Disorder n STPP = CBT (response rates)

Anxiety Disorders

n Crits-Christoph et al. (2005): GADn STPP > Supportive Therapy (remission rates)

n Leichsenring et al (2009): GADn STPP = CBT; STPP < CBT

Anxiety Disorders

n Knijnik et al. (2004): Social Phobian STPP > Placebo

n Bögels et al. (2015): Social Phobian STPP = CBT

n Leichsenring (2013, 2014): Social Phobia

Large-scale multicenter RCT in social phobia: SOPHO-NET *

n Leichsenring et al (2013, 2014, Am J P)

n N=494 patients with Social Phobia

n STPP vs CBT vs Waiting list

n N= 207 vs. 209 vs 79

* funded by BMBF (German Federal Ministery of Research and Education)

Large-scale multicenter RCT in social phobia: SOPHO-NET

CBT vs STPP

n CBT = STPP (response rates): 60% vs 52%

n CBT > STPP (remission rates): 36% vs 26%

n all differences were small (h ≤ 0.23) and below a priori set margin of 15%

Large-scale multicenter RCT in social phobia: SOPHO-NET

n Follow-up: 6, 12, 24 months

n Treatment effects were stable, tending to increase

n CBT = STPP

Meta-Analysis in Anxiety Disorders

Keefe, McCarthy, Dinger, Zilcha-Mano, Barber (2014)

n STPP > Controls (WL, Supportive Therapie): g=0.64

n STPP = other therapies n Post: g = 0.02n ≤ 1-YFU: g = -0.11n > 1Y FU: g = -0.26

Somatoform Disorders

n Guthrie al. (1991): irritable bowl syndrome§ STPP > TAU

n Creed et al. (2003): irritable bowl syndrome§ STPP > TAU

n Hamilton et al. (2000): chron. functional dyspepsia§ STPP > Supportive Therapie

n Monsen & Monsen (2000): somatof. pain disorder § STPP > control (no treatment or TAU)

n Sattel et al (2011): somatoform disorders§ STPP >TAU (enhanced medical care)

Somatoform Disorders

Meta-Analysis (Abbass, Kisley, Kroenke, 2009)

n Somatic Disorders

n STPP > Controls

n effects stable in follow-up

n improvements in physical and psychological symptoms, social functioning

Personality DisordersCluster C

n RCTsn Winston et al. (1994): Cluster C Personality Disorders

n STPP > Waiting List n Svartberg et al. (2004): Cluster C Personality Disorders

n STPP = CBT n Muran et al. (2005): Cluster C Personality Disorders

n STPP = CBT= brief relational therapy

n Abbass et al. (2008): Personality Disordersn STPP > minimal contact

Borderline Personality Disorder

n Bateman & Fonagy (1999; 2001)n LTPP (MBT) > TAU

n Bateman & Fonagy (2009) n LTPP (MBT) > Structured Clinical Managem.

n Clarkin et al (2007) n LTPP (TFP) ³ DBT, SupportiveTherapy

n Doering et al (2010)n LTPP (TFP) > TAU (experienced community therapists)

n Gregory et al (2008) n LTPP > TAU

Borderline Personality Disorders

Meta-Analysis (Cristea et al., 2017)

n PDT > Controls (TAU, other therapies): g=0.41

n DBT > Controls (TAU, other therapies): g=0.35

n CBT = Controls (TAU, other therapies): g=0.24 n.s.

Eating Disorders

n Bulimia Nervosan Fairburn et al. (1986, 1995)

n STPP = CBT (bulimic episodes, vomiting)n Garner et al. (1993)

n STPP = CBT (bulimic episodes, vomiting)n Poulsen et al. (2014): LTPP < CBT

n Bachar et al. (1999) n STPP > Cognitive Therapy n STPP > Control (nutritional counseling)

Eating Disorders

n Anorexia Nervosan Gowers et al. (1994)

n STPP > TAU

n Dare et al. (2001) n STPP > TAU

n Binge Eating (Tasca et al. 2006)§ STPP = CBT > Waiting list (e.g. days binged)

Anorexia Nervosa

Zipfel, Herzog et al (Lancet, 2013)

n LTPP vs E-CBT vs O-TAU (Primary Outcome: BMI)

n N = 80 : 80 : 82

n Sessions: LTPP: 39.9 E-CBT:44.8 O-TAU: 50.8

n LTPP = E-CBT = O-TAU

Anorexia Nervosa

Zipfel, Herzog et al (Lancet, 2013) 12 MFU: recovery (PSE 1 or 2 and BMI > 18.5): n LTPP: 35%n E-CBT: 19%n O-TAU: 13%

n LTPP > O-TAU n E-CBT= O-TAU n LTPP vs E-CBT: n.s.

PTSD

n STPP= CBT= Hypnotherapy (Brom et al., 1989)

n STPP > Waiting list (Steinert et al., 2016, 2017)

Further Evidence

n Alcohol misuse: STPP= CBT (Sandahl et al., 1989)

n Opiat Addiction:

§ STPP=CBT>Drug Counseling (Woody et al., 1990)

§ STPP >Drug Counseling (Woody et al. 1995)

Short- vs. long-term Psychotherapy

Short- vs. Long-Term Psychotherapy:Dose–effectiveness relationships

n Acute mental problems: 20 sessions are sufficient to achieve remission in 70% of patients (Kopta et al., 1994)

n Chronic mental disorders: 50 sessions required for remission of 70% of patients (Kopta et al., 1994)

n Personality Disorders: 50 sessions are nor sufficient for remission of 50% of patients (Kopta et al., 1994)

Improving Access to Psychological Therapies: (IAPT)

n low intensity CBT (< 8 sessions, in person or via telephone, assisted by computerized learning modules )

n 53% of remitters relapsed within 1 year (Ali et al., 2017)

n the majority (79% ) relapsed within the first 6 months post-therapy (Ali et al., 2017)

Short- vs. Long-Term Psychotherapy:Dose–effectiveness relationships

There is a time for everything …

Meta-Analysis: LTPP*

n LTPP (at least 50 sessions or 1 year)n Complex Mental Disorders: chronic, multimorbid,

personality disorders n overall outcome, target problems, general symptoms,

personality functioning, and social functioning n Large effect sizes for LTPPn stable in FU; increased significantly during FUn LTPP > shorter forms of treatment (8 studies)

* Leichsenring, F & Rabung, S, E (2008). Effectiveness of long-term psychodynamic therapy: a meta-analysis JAMA, 300, 1551-1564.

Meta-Analysis of LTPP*: an update

n LTPP (at least 50 sessions or 1 year)n Complex Mental Disorders n 10 controlled studiesn LTPP > shorter forms of treatmentn Between-group effect sizes

n Overall 0.54n Target problems 0.49n General psychiatric problems 0.44n Personality functioning 0.68n Social functioning 0.62

* Leichsenring, F Rabung, S (2011). Long-term psychodynamic psychotherapy in complex mental disorders: update of meta-analysis. British Journal of Psychiatry, 199, 15-22.

LTPP: Another update 2013

n Leichsenring, Abbass, Luyten, Hilsenroth, Rabung (2013)

n Results were corroborated

* Leichsenring et al (2013). The emerging evidence for long-term psychodynamic psychotherapy. Psychodynamic Psychiatry, 41, 361-384.

Long-term Psychodynamic Therapy

n Results support those reported by Olavi Lindfors

and Felicitas Rost

Reviews

Cochrane Report (2014) Abbass, Kisley, Town, Leichsenring, Driessen, deMaat,

Gerber, Dekker, Rabung, Rusalovska, Crowe

n STPP vs. Controls

n Common mental disorders (dep, anx, personality etc.)

n Depressive symptomsn anxiety symptomsn somatic symptomsn general psychiatric symptoms

Cochrane Report (2014) Abbass, Kisley, Town, Leichsenring, Driessen, deMaat,

Gerber, Dekker, Rabung, Rusalovska, Crowe

STPP > Controls

n short-term ≤ 3-MFU

n medium-term 3-6-MFU

n long-term: effect sizes tended to increase (n.s.)

Reviews

n Leichsenring, Leweke, Klein, Steinert (2015). The

empirical status of psychodynamic therapy: an update

– Bambi´s alive and kicking. Psychotherapy and

Psychosomatics, 84, 129-148

Reviews

n Leichsenring, Luyten, Hilsenroth, Abbass, Barber, Keefe,

Leweke, Rabung, Steinert (2015). Psychodynamic

therapy meets evidence-based medicine: a systematic

review using updated criteria. The Lancet Psychiatry, 2,

648-660.

Meta-Analysis (Steinert et al., 2017): Am J P

• Is PDT as efficacious as treatments established

in efficacy ?

• Controlled for researcher allegiance

• Logic of equivalence testing

• margin (g=0.25)

• two-one-sided tests (TOST)

Meta-Analysis (Steinert et al., 2017): Am J P

• across disorders (e.g. depressive, anxiety,

personality disorders)

• PDT as effcacious as established treatments

• PDT as efficacious as CBT

Conclusions

Evidence for efficacy of psychodynamic therapy in:

n Depressive Disordersn Anxiety Disorders (GAD, Social Phobia, Panic Disorder)n PTSD n Somatoform Disordersn Eating Disorders (Anorexia, Bulimia, Binge Eating)n Personality Disorders (Cluster C; BPD)n Substance-related Disorders

Several approaches exist: e.g. CBT, PDT, IPT …

Is there a Gold Standard for

Psychotherapy ?

Is CBT the gold standard for Psychotherapy ? (Leichsenring & Steinert, 2017, JAMA)

n Leichsenring & Steinert (2017, JAMA), we reviewed

n study quality

n efficacy (response rates)

n evidence for superiority

n meta-analyses or reviews by independent researchers

Is CBT the gold standard for Psychotherapy ? (Leichsenring & Steinert, 2017, JAMA)

n Study Quality is limited: 17% (24/144) of high quality (Cuijpers et al., 2016)

n Weak empirical tests: in 80% of 121 studies in anx dis test against waiting list (Depresson: 44%) Cuijpers et al 2016

n Uncontrolled researcher allegiance: neutering of control conditions (Wampold et al 2017: Clark et al, 1994, Gilboa–Schechtman et al 2010; Durham et al. 1994)

Is CBT the gold standard for Psychotherapy ? (Leichsenring & Steinert, 2017, JAMA)

n Mechanisms of change were not corroborated (e.g. negative triad, Kazdin, 2007)

n Limited efficacy: CBT is not a panacea (e.g. response: 50% in anxiety or depress dis) : Cuijpers et al, 2014, Craske & Stein 2017

n No clear evidence of superiority, e.g. in depr. or anx. disorders (Cuijpers et al, 2014; Tolin et al, Keefe et al)

Is CBT the gold standard for Psychotherapy ? (Leichsenring & Steinert, 2017, JAMA)

n no form of psychotherapy can presently claim to be the gold standard

n neither CBT, PDT, IPT or any other form

n monocultures not successful (e.g. only CBT)

n different approaches may be helpful to different patients

German Health Care System

German Health Care System

n PDT was shown to sign. reduce the days in hospital (Dührssen & Jorswieck 1965)

n PDT sig. reduced costs

n 1967 insurance companies decided to reimburse PDT

n 1987: CBT was included

n cost reduction was corroborated (Margraf et al, 2009)

German Health Care Sytsem

n Psychodynamic therapy and CBT: „Richtlinientherapien“, i.e. reimbursed by the insurance companies

n CBT and PDT are equally frequently applied.

n CBT: 24 - 80 sessions

n PDT: 24 - 100 sessions

n Psychoanalytic therapy: 80-300 sessions

n Mean: about 50 sessions (CBT, PDT, Psa)

Thank you for your attention !